ABSTRACT
BACKGROUND: Antimicrobial stewardship (AMS) program aims to optimise antimicrobial utilisation and curb antimicrobial resistance. We investigated the clinical impact of AMS among patients with carbapenem in medical wards of a tertiary hospital. METHODS: A retrospective cohort study was conducted on hospitalised adult patients treated with carbapenem and reviewed by a multidisciplinary AMS team. We compared the clinical outcomes of accepted (n = 103) and not-accepted AMS intervention cases (n = 37). The outcomes evaluated include trends of total white blood cells (TWBC), C-reactive protein (CRP), body temperature at day-7, and clinical status at day-30 post-AMS intervention. RESULTS: The interventions included discontinuation (50%), de-escalation (47.9%) and escalation (2.1%) of antibiotics, where the acceptance rate was 67.1%, 80.6% and 66.7%, respectively. Overall, we found no significant difference in clinical outcomes between accepted and not-accepted AMS interventions at day-7 and day-30 post-interventions. On day-7, 62.0% of patients in the accepted group showed decreased or normalised TWBC and CRP levels compared to 47.4% of the not-accepted group (p = 0.271). The mortality at day-30 (32% versus 35%, p = 0.73), discharge rate (53.4% versus 45.9%, p = 0.437), and median length of hospital stay (36.0 versus 30.0 days, p = 0.526) between the groups were comparable. The predictors of 30-day mortality in the study subjects were Charlson Comorbidity Index > 3 (OR: 2.84, 95% CI 1.28-6.29, p = 0.010) and being febrile at day-7 (OR: 4.58, 95% CI 1.83-11.5, p = 0.001). CONCLUSION: AMS interventions do not result in significant adverse clinical impact and mortality risk.
ABSTRACT
BACKGROUND: More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. This study aims to compare the survival curve of patient de-escalated (early or late) against those not de-escalated on antibiotics, to determine the association of patient related, clinical related, and pressure sore/device related characteristics on all-cause 30-day mortality and determine the impact of early and late antibiotic de-escalation on 30-day all-cause mortality. METHODS: This is a retrospective cohort study on patients in medical ward Hospital Kuala Lumpur, admitted between January 2016 and June 2019. A Kaplan-Meier survival curve and Fleming-Harrington test were used to compare the overall survival rates between early, late, and those not de-escalated on antibiotics while multivariable Cox proportional hazards regression was used to determine prognostic factors associated with mortality and the impact of de-escalation on 30-day all-cause mortality. RESULTS: Overall mortality rates were not significantly different when patients were not de-escalated on extended or restricted antibiotics, compared to those de-escalated early or later (p = 0.760). Variables associated with 30-day all-cause mortality were a Sequential Organ Function Assessment (SOFA) score on the day of antimicrobial stewardship (AMS) intervention and Charlson's comorbidity score (CCS). After controlling for confounders, early and late antibiotics were not associated with an increased risk of mortality. CONCLUSION: The results of this study reinforce that restricted or extended antibiotic de-escalation in patients does not significantly affect 30-day all-cause mortality compared to continuation with extended and restricted antibiotics.
ABSTRACT
BACKGROUND: In Malaysia, for more than a decade, dipeptidyl peptidase-4 inhibitors (DPP-4i) are among the oral antidiabetic medications used as monotherapy or in combination to manage type II diabetes mellitus (T2DM). These medications are known for the efficacy in glycated haemoglobin (HbA1c) reduction and weight neutral effect with minimal hypoglycaemia occurrence. This study aimed to identify the outcomes of DPP-4i use in one of the largest tertiary public hospital in Southeast Asia. METHODS: This is a retrospective cross sectional study conducted in 2016, where stratified sampling method was used. Patients with T2DM treated with available DPP-4i; namely Linagliptin, Saxagliptin, Sitagliptin and Vildagliptin, for at least 3 months were identified from the pharmacy record. Medical records from Physician Clinic in Hospital Kuala Lumpur (HKL) were reviewed. Data on demographic, anthropometric, antidiabetic treatment modalities, laboratory and documented outcomes were collected. Outcomes endpoints which include changes in HbA1c, fasting blood glucose (FBG), and body weight were recorded and analysed. Adverse drug reactions (ADR) documented were also reported. RESULTS AND DISCUSSION: A total of one hundred and five patients were recruited. The patients were 49.5% men (n = 52), with a mean age of 57 years, mean HbA1c of 8.5% (69 mmol/mol) and mean BMI of 29.5 kg/m2. At least 50% of the patients had T2DM for more than 10 years and more than two third of these patients had both T2DM and hypertension. Thirty nine patients were on Vildagliptin, 32 on Sitagliptin, 26 on Saxagliptin and the remaining on Linagliptin. The most commonly prescribed DPP-4i were Vildagliptin and Sitagliptin. Majority of the patients (90.4%) were prescribed with Metformin, with 62.8% of patients on fixed-dose combination, and the remaining on add-on Metformin therapy. Use of DPP-4i as an adjunct was associated with a mean reduction of 0.9% (9 mmol/mol) in HbA1c (p < 0.0001) and 1.15 mmol/L (19.82 mg/dL) in FBG (p = 0.001) without significant weight changes (p = 0.745). Sitagliptin had the highest reduction in HbA1c (1.66%,19 mmol/mol; p-value< 0.0001). Twelve ADRs were reported with the highest report on gastrointestinal intolerance (n = 7). None of the ADR reported caused any significant harm to the patients. CONCLUSION: Overall, use of these DPP-4i as an adjunct antidiabetic was associated with reduction in HbA1c.
